Treatment of stage A heart failure should focus on reducing modifiable risk factors, including management of hypertension and hyperlipidemia.

To prevent symptomatic heart failure, ACE inhibitors and beta blockers should be used in all patients with stage B or C heart failure who have a reduced ejection fraction.

Patients with stage C heart failure and fluid retention should be treated with diuretics in addition to ACE inhibitors and beta blockers.

—From the AFP Editors

Heart failure is a complex clinical syndrome that results from structural or functional impairment of ventricular filling or ejection of blood. It may result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels, or from metabolic abnormalities, but most patients have symptoms resulting from impaired left ventricular myocardial function. Manifestations include dyspnea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary congestion and peripheral edema.

The American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) recently developed guidelines on the diagnosis and treatment of heart failure. The guidelines are based on four progressive stages of heart failure; progression from one stage to the next is associated with reduced five-year survival and increased plasma natriuretic peptide concentrations. Stage A includes patients at risk of heart failure who are asymptomatic and do not have structural heart disease. Stage B describes those with structural heart disease who do not have signs or symptoms of heart failure; it includes New York Heart Association (NYHA) class I, in which there are no limitations on physical activity. Stage C describes patients with structural heart disease who are currently symptomatic or have a history of heart failure symptoms, and includes NYHA classes I, II (slight limitation of physical activity), III (marked limitation), and IV (unable to engage in physical activity without symptoms, or symptoms that occur at rest). Stage D describes patients with refractory heart failure who require specialized interventions; it includes NYHA class IV. Interventions at each stage are aimed at modifying risk factors (stage A), treating structural heart disease (stage B), and reducing morbidity and mortality (stages C and D).

Diagnostic Testing

Because heart failure is largely a clinical diagnosis based on findings from the history and physical examination, there is no single diagnostic test. The initial laboratory evaluation should include a complete blood count, urinalysis, fasting lipid profile, liver function testing, and measurement of serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine,